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Publisher: Routledge
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office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
To cite this article: Michele R. Cooley-Strickland , Robert S. Griffin , Dana Darney , Katherine
Otte & Jean Ko (2011): Urban African American Youth Exposed to Community Violence: A School-
Based Anxiety Preventive Intervention Efficacy Study, Journal of Prevention & Intervention in the
Community, 39:2, 149-166
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Journal of Prevention & Intervention in the Community, 39:149–166, 2011
Copyright # Taylor & Francis Group, LLC
ISSN: 1085-2352 print=1540-7330 online
DOI: 10.1080/10852352.2011.556573
MICHELE R. COOLEY-STRICKLAND
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland, and the Center for Culture and Health, Department of Psychiatry,
NPI-Semel Institute for Neuroscience, University of California–Los Angeles,
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ROBERT S. GRIFFIN
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland, USA
DANA DARNEY
Department of Educational, School & Counseling Psychology, University of Missouri,
Columbia, Missouri, USA
This research was supported by grants from the National Institute of Mental Health (PI:
Cooley; R21 MH63143) and the National Institute on Drug Abuse (PI: Cooley; R01 DA018318).
We extend our gratitude to the Baltimore City Public School System and the principals,
teachers, parents, caregivers, and students who participated in the FRIENDS Program.
Address correspondence to Michele R. Cooley-Strickland, Department of Psychiatry,
NPI-Semel Institute for Neuroscience, University of California–Los Angeles, Center for Culture
and Health, 760 Westwood Plaza, Box 62, B7437, Los Angeles, CA 90024-1759, USA. E-mail:
mcooley@mednet.ucla.edu
149
150 M. R. Cooley-Strickland et al.
interventions
METHOD
Participants
Participants (N ¼ 93) were African American (92%) and biracial (8%) students
8 to 12 years old (grades 3–5; 48% female), in two Title 1 public elementary
schools located in Baltimore, MD. Both schools were located in economically
disadvantaged urban communities (average of 90% of the student bodies
received free or reduced lunch) characterized by high crime.
Intervention
FRIENDS (Barrett & Turner, 2001; Barrett et al., 2000) is a group-oriented
CBT selected anxiety prevention program that targets students with mild to
moderate anxiety disorders. The cognitive, physiological, and behavioral
components of the FRIENDS Program teach children specific strategies for
coping with anxiety, including problem-solving skills and skills to cope with
fearful stimuli. During the sessions didactic lessons were taught by the group
leaders, then students participated in activities and role-plays to practice the
new skills. Students were given weekly homework assignments to help
Prevention Among Community Violence Exposed Youth 153
generalize the skills they learned to the classroom and home environments.
Examples of session content include: identifying physiological symptoms of
anxiety (e.g., students were taught to identify emotions and body cues),
learning relaxation techniques (e.g., deep breathing and visualization), and
engaging in positive feelings, thoughts, and self-talk as they actively face
challenges and fears.
FRIENDS is an acronym for the skills it teaches, which stands for: F—
Feeling worried?; R—Relax and feel good; I—Inner thoughts; E—Explore
plans; N—Nice work so reward yourself; D—Don’t forget to practice; and
S—Stay calm, you know how to cope now (Shortt et al., 2001). The current
preventive intervention program was based on the FRIENDS Program
(Barrett, Lowry-Webster, & Holmes, 1999), albeit modified to be culturally
and contextually appropriate for ethnically diverse urban American children,
particularly African Americans. The guiding principle of this adaptation was
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Measures
Exposure to community violence was assessed using the Children’s Report of
Exposure to Violence (CREV; Cooley, Turner, & Beidel, 1995). The CREV is a
widely used self-report questionnaire developed to assess children’s lifetime
exposure to community violence. It has good two-week test–retest reliability
(r ¼ .75), internal consistency (overall a ¼ .78), and construct validity (Cooley
et al., 1995). Twenty-nine scored CREV items are rated on a 5-point Likert
scale, ranging from 0—‘‘no, never’’ to 4—‘‘everyday,’’ to indicate the fre-
quency of exposure to community violence via four modes (i.e., media, hear-
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Procedure
BASELINE SCREENING AND SELECTION OF PARTICIPANTS
A two-stage screening process identified children for participation in the
FRIENDS Program. First, parents=guardians of students in the 3rd through
5th grades in regular education or resource classes at the two urban public
elementary schools were mailed letters of notification informing them of
the RCMAS (Reynolds & Richmond, 1978) and CREV (Cooley et al., 1995)
administration at their child’s school with an option to decline participation.
Children who assented and whose parents=caregivers provided permission
were administered the RCMAS and CREV in groups by classroom (12 classes
in two schools; 330 [82%] students were assessed out of 404 in the combined
student body). Teachers in each classroom (n ¼ 16) nominated up to three
very anxious students, following Dadds, Spence, Holland, Barrett, and Lau-
rens (1997) procedure, resulting in 34 students who were automatically con-
sidered for the next level of eligibility in the project. Consistent with other
school based interventions (e.g., Stein et al., 2003), teachers were also asked
to identify up to three children in their classrooms who were extremely dis-
ruptive or aggressive and therefore would not be appropriate for group ses-
sions. Those 51 students were eliminated from the project although their
exclusion did not eliminate all anxious children with co-occurring aggressive
behavior from the FRIENDS program. Children were included and eligible
for further consideration for the FRIENDS program if they: (1) had a CREV
Total score > 10; and (2) either a RCMAS T-score of 51 or higher or were
included in the teachers’ nominations of anxious children. They were
excluded if they were not in regular education or resource classes or had
been nominated by teachers as extremely disruptive.
In the second stage of screening, parents of the 207 eligible students
were asked to provide written consent for their child to participate in a
156 M. R. Cooley-Strickland et al.
RESULTS
TABLE 1 Baseline Characteristics of the FRIENDS Intervention and Control group (N ¼ 93)
Intervention Control
group (n ¼ 48) group (n ¼ 45) Chi-squared
Variables n (%) n (%) (df)
Gender
Males 24 (0.5) 24 (0.53) 0.35 (2)
Females 24 (0.5) 21 (0.47)
Race=Ethnicity
African American 45 (0.94) 40 (0.89) 0.74 (2)
Mixed=Biracial 3 (0.06) 5 (0.11)
Age Equivalent
MESA total score 17.96 (9.48) 18.57 (9.41) 1.79 (2)
(df) ¼ 14.88(1); p < .01) such that the program participants from one school
were 97.7% African American and 2.3% biracial (22.9% of the neighborhood
residents lived below the poverty level), whereas the other were 75.8%
African American and 24.2% biracial (8.6% of neighborhood residents lived
below poverty).
Within-Group Comparisons
Paired t-tests were used to investigate within-group changes on community
violence exposure, academic performance, and psychosocial outcomes
(Table 2). Both groups showed significant reductions in their Total
exposure to community violence at post-intervention compared to baseline
(Table 2; ps < .01). The intervention group also experienced a mean
reduction in community violence victimization; the control group did not
(p > .05). Significant reductions in overall anxiety, as measured by total
RCMAS score, were observed in both groups at post-intervention from base-
line (ps < .01). Reading performance significantly improved from baseline to
post-intervention in both groups (WIAT Reading age equivalent; ps < .05).
The FRIENDS intervention group’s mathematics performance score also sig-
nificantly improved, although the control group’s did not. The intervention
group was performing mathematical skills at the mean equivalent of a
9.6-year-old (SD ¼ 1.9) at baseline, and the equivalent of a 10-year-old
(SD ¼ 1.8) at post-intervention (p < .01). The intervention, but not control,
group had significant reductions in adverse life events, as measured by
the Total MESA score (p < .01).
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CREV total 33.7 (13.4) 19.4 (14.0) 14.3 (17.3) 36.0 (18.1) 25.6 (15.9) 10.4 (16.7)
CREV victimization 1.8 (2.1) 0.6 (1.2) 1.1 (1.9) 1.7 (1.6) 1.0 (1.7) 0.6 (2.3)
158
RCMAS total 17.1 (4.7) 12.1 (6.5) 5.0 (6.7) 15.8 (5.3) 10.9 (4.7) 5.0 (5.9)
WIAT Reading 9.5 (1.4) 10.2 (1.9) 0.7 (0.9) 9.9 (1.4) 10.3 (1.7) 0.4 (0.8)
(Age equivalent)
WIAT Math 9.6 (1.9) 10.0 (1.8) 0.4 (0.9) 9.7 (1.3) 9.8 (1.1) 0.2 (0.6)
(Age equivalent)
MESA total 17.4 (9.2) 12.7 (12.4) 4.7 (9.5) 18.6 (9.6) 14.8 (11.4) 3.9 (12.3)
Note. p < .01.
Prevention Among Community Violence Exposed Youth 159
Between-Group Comparisons
A two-group repeated measures MANOVA, controlling for baseline mea-
sures, was conducted to investigate the differences across baseline and
post-intervention for the FRIENDS intervention versus control group. The
two groups did not significantly differ on the major variables of interest
(CREV, RCMAS, WIAT, MASC, behavior change, program likeability; no
group by time interactions were found; ps > .05; data not shown). A time
effect was observed, as the entire sample had lower levels of anxiety
(RCMAS; F(1,71) ¼ 10.139; p < .01) and improved scores on age-based WIAT
Reading performance (F(1,70) ¼ 5.26; p < .05).
DISCUSSION
Limitations
One limitation of the current study is frequently found in school- and
community-based research projects involving ethnic minority participants:
Low parental consent rates. Students are prevented from reaping potential
benefits of school-based mental health programs if their parents do not
consent to their participation (Stein et al., 2007). Parental permission and
child assent rates obtained during the first stage of screening were accept-
able (82%), but parental consent was only in the low-moderate range
(59%) in the second stage despite active recruitment strategies. The most
effective mechanism for parental cooperation was linked to building the
school community’s trust over time and enhancing the parent’s relationship
and comfort with the school. Nonetheless, as a result of the relatively small
and highly selected sample, the study’s power and generalizability are
restricted.
There were exceptions (WIAT Screener, C-DISC) but the majority of out-
come measures reported in this study are self-report questionnaires. Data
from additional informants at pre- and post-intervention would have
strengthened this investigation, as would behavioral measures of the efficacy
of the FRIENDS intervention (e.g., psychophysiological, neurobehavioral
assessments). The study was designed to obtain both teacher and parent
reports. The former was obtained as part of the screening procedure (i.e.,
teacher nominations), but neither was obtained for the outcome measures.
The original approach of sending parental report forms home for parents=
caregivers to complete proved to be inadequate and was discontinued.
Future studies should allocate sufficient resources to obtain outcome data
162 M. R. Cooley-Strickland et al.
but the intervention group maintained their treatment gains over 6 and
24 months whereas the control group did not. Another study did not find sig-
nificant changes in children’s self-reported anxiety in an efficacy study of the
FRIENDS intervention, although parental reports indicated significantly
decreased anxiety among children who participated in the intervention com-
pared to the controls (Bernstein et al., 2005), suggesting the importance of
involving parents as informants in studies involving anxious children.
The current study lacked a clearly delineated comparison group, which
also may have contributed to the failure to find between-group differences,
yet there were within-group differences. The FRIENDS Team was given a
classroom in the school where both intervention and control group students
completed their assessment batteries and were welcomed to visit (i.e., get
snacks, draw, chat). FRIENDS staff became active and integrated members
of the school community (e.g., attended school events, Back-to-School Night,
PTA meetings, talent shows, basketball games). Control students reported
liking being ‘‘members of the FRIENDS Team’’ as much as the intervention
participants. Some reported the FRIENDS program was the only organized
‘‘team’’ to which they belonged, a reflection of the under-resourced environ-
ments in which they lived. The unanticipated impact of this relationship may
have attenuated distinctions between the intervention and control groups, at
least in the short-term and may speak to the power of creating community
and meaningful relationships beyond the proscribed intervention.
Future Studies
It is well established that African American youth are less likely than
European Americans to receive appropriate treatment for anxiety problems
(Young, Klap, Sherbourne, & Wells, 2001). After school programs may be
ideal venues for time- and resource-intensive interventions because they pro-
vide the security and resources of the school setting, community accessibility,
Prevention Among Community Violence Exposed Youth 163
and reduced costs and stigma associated with clinical settings. The FRIENDS
Program was implemented in only 13 contact hours with the students, yet
resulted in significant gains for this underserved population. It speaks to
the need to continue to develop comprehensive, multi-component preven-
tive intervention efforts that target not only anxiety, but also developmen-
tally, ecologically, culturally and contextually appropriate factors within a
community environment. Future studies designed to prevent the adverse
effects of youth’s exposure to stressful community violence should involve
larger sample sizes, longer-term follow-ups, more comprehensive preventive
intervention programs, and comprehensive multi-informant assessments of
cognitive, neuropsychological, behavioral, academic, and=or social out-
comes, not just those constructs directly related to anxiety. Understanding
developmental timing and optimal dosage levels are also important.
Cost-effectiveness studies are needed, as preventive and treatment interven-
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REFERENCES
Bernstein, G., Layne, A., Egan, E., & Tennison, D. (2005, November). School-based
interventions for anxious children. Journal of the American Academy of Child &
Adolescent Psychiatry, 44(11), 1118–1127.
Birmaher, B., Bridge, J. A., Williamson, D. E., Brent, D. A., Dahl, R. E., Axelson, D. A.,
. . . Ryan, N. D. (2004). Psychosocial functioning in youths at high risk to
develop Major Depressive Disorder. Journal of the American Academy of Child
and Adolescent Psychiatry, 43, 839–846.
Boyd, R., Cooley, M., Lambert, S., & Ialongo, N. (2003). First-grade child risk beha-
viors for community violence exposure in middle school. Journal of Com-
munity Psychology, 31, 297–314.
Bryant, C. E., & Harder, J. (2008). Treating suicidality in African American adoles-
cents with cognitive-behavioral therapy. Child and Adolescent Social Work
Journal, 25(1), 1–9.
Cole, D., Peeke, L., Martin, J., Truglio, R., & Seroczynski, A. (1998). A longitudinal
look at the relation between depression and anxiety in children and adoles-
Downloaded by [131.245.211.178] at 22:22 18 March 2013
Shortt, A., Barrett, P., & Fox, T. (2001). Evaluating the FRIENDS Program: A
cognitive-behavioral group treatment for anxious children and their parents.
Journal of Clinical Child Psychology, 30(4), 525–535.
Stallard, P., Simpson, N., Anderson, S., Hibbert, S., & Osborn, C. (2007). The
FRIENDS Emotional Health Programme: Initial findings from a school-based
project. Child and Adolescent Mental Health, 12(1), 32–37.
Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., et al.
(2003). A mental health intervention for school children exposed to violence.
Journal of the American Medical Association, 290(6), 603–611.
Ward, C. L., Martin, E., Theron, C., & Distiller, G. B. (2007). Factors affecting resili-
ence in children exposed to violence. South African Journal of Psychology,
37(1), 165–187.
Wolfe, S., Toro, P., & McCaskill, P. (1999). Comparison of homeless & matched
housed adolescents on family environment variables. Journal of Research on
Adolescence, 9, 53–66.
Downloaded by [131.245.211.178] at 22:22 18 March 2013
World Health Organization. (2002). World report on violence & health. Brussels,
Belgium: Author.
Young, A., Klap, R., Sherbourne, C., & Wells, K. (2001). The quality of care
for depressive & anxiety disorders in the United States. Archives of General
Psychiatry, 58, 55–61.